Patient Demanding

[sjdcMD]

Today i start my shift off pretty well. 22 yr old male comes in with "intractable back pain". From the start i knew just another drug seeker. Do a full exam. Pt showing no signs of distress. Of course his junkie girlfriend gives me the full run down of what happend. I quess the patient can't think to make up lies anymore. The patient GF rambles on and dictates to me what dose and medication to give him. And is allergic to NSAIDs and other non narcs. She said that is the only medication he can have and 10mg is not enought. I just wanted to get up and walk out. I saw no medical need for narcs. So i sent them with no script. Then i get called from the nursing supervisior "why didn't you just give it to them" i can't stand nursing telling me to prescribe narcs, i said for what no evidence of medical distress. i quess they are the MD's now.

What would be some soultions from your experience.

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[deleted77919]

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[TysonCook]

...agreed. Nursing should bring it to your attention but not question your MDM. Overall, discuss it with your department director and +/- head of nursing.

DO NOT give in, see the other threads on this. Overall it is becoming a HUGE pandemic that needs to be curtailed.

I also have police/security escort out frequently. STICK TO YOUR GUNS, and if questioned by admin/RN etc, reply with a quick "are you really being serious..."

 

[EM_Rebuilder]

I agree that being questioned by a nurse is never very comforting. My personal approach, espically with difficult patients, is to try to involve the nurse with my decision....

If I think the patient is a seeker and trying to be abusive; I like to ask that patients nurse opinon about it too. I think it helps to prevent me from having bias; and listen to what the nurses opinon is and why. If you are 180 opposite from the nurse, have a quick discussion. Its ok to be swayed every once in a while. After nurse conversations I have went both ways from going ahead and giving the script/drug/etc and have went ahead and revoked the decision. The discussion can be very different depending on if you have a brand new nurse, or really 'experienced nurse'... also depending on how long you have worked in the shop you are in.

I think the above overall gives better patient care and fosters a much better work enviroment... I think in the end, a nurse that at least thinks you listened/cared to what they had to say, is less likely to cause you a problem and may have your back one day...

I'll do the same discussion sometimes on a complicated patient requiring many labs/meds.... Again, I think involving the nurses helps the team approach that many hospitals are striving for.

Obviously time becomes a big factor; also places that all full computer ordering seem to hinder the discussion. I am a huge fan of computer based charting, but I do not like computer based ordering yet...

 

[The right Path]

From a nursing standpoint.... who would want these individuals to get the impression that their hospital is the go-to place for easy narcs?

Granted, I don't work in the ED, but I would think that you'd have the support of the nursing staff to nip that crap in the bud.

What was that nursing supervisor thinking?

 

[RustedFox]

I, for one - am seriously 'sick-and-tired' of being accosted by NurseBosses that are questioning my MDM. Granted, I am a senior resident and I haven't yet learned all that I can.. but when it comes down to the simple things... the last thing that I need is another RN-busybody coming to me for the sole purpose of feeling 'good about herself' and 'correcting' an MD when it comes down to what-to-do-and-why. I look around my department , and I can count...

A "Nurse Supervisor"
A "Nurse Manager"
A "Nurse Administrator"
.... and so on and so forth....

Mind you, the last two above have done nothing more than tell me where I can and cannot place my coffee, and hassle me about "the perception of how we operate here as a unit."

They want to make all of the decisions, and want to hoist none of the accountability... and CERTAINLY don't want to actually have 'rooms' to care for.

Use...less...

 

[sjdcMD]

Exactly her thought is because our press ganey is in the ****ter that its on the MD's. Well if a drug seeker recieves a press ganey 8 out 10 times they will not even open the mail, half the time they don't even have a address, or its a hotel address. Or they give a fake name like come on with all these nursing managers, nursing supervisor, nursing assistant. I am tired of their bull****. Like is me giving them the 30mg oxycodone they want going to up our press ganey scores.No they would rather see that patient walk out with what they want and go sell it to a 15yr. I would rather have the press ganey in the ****ter then have them selling drugs to the adolesences. Well maybe you should consider to fire all of the nasty nurses that walk around with a attitude. Next time a nurse confronts me i am going to walk away. If you want to be the MD go to medical school.

 

[Groove]

My opinion is that the ED isn't a narc clinic and ED physicians shouldn't be pandering to drug addicts. They can't fill out a Press-Ganey if they've been there within 90 days. Most drug seekers are very frequent fliers. The MD management position shouldn't depend on whether the nurse approves or not, period.

That being said, it probably depends on what kind of shop you're in and whether the culture of your department is to "give in" or not. I would imagine if you choose to be the only one to stand up to these guys, you'll start getting some heat. There's probably a fine line between standing up for your medical ethics and job security. After all, it's not like people coming to the ED for pain meds is anything new. It's also hard to prove someone isn't in 10/10 pain by documentation alone or justify not treating their pain. If you're gonna be 'that guy" in your group, it probably would be good to bring the topic up with your colleagues and form a generalized consensus or agreement on how to manage these patients. Personally though, I think if we don't' make it uncomfortable for these people and risk some unpleasant reactions, they'll just keep coming back. I can't imagine pandering to these guys when I'm finished with residency.

Hell, try tricking them with a paracetamol Rx for 500mg tid, or dolobid 500mg bid, grow their allergy list as ridiculous as possible.

 

[sjdcMD]

I just can't understand why nursing staff question my decision. I gave narc's when needed. I don't just say "oh there drug seeking" and send them on their merry way. Its just when the seekers whine and cry and roll on the floor i know i am getting a call from some nurse.

 

[DrMom]

Pass this along to the nursing staff. It's stuff we all know, but some nurses are too concerned about being "nice" and the all powerful and misused pain scale to realized that they're being duped.

http://www.deadiversion.usdoj.gov/pubs/brochures/drugabuser.htm

 

[southerndoc]

Exactly her thought is because our press ganey is in the ****ter that its on the MD's. Well if a drug seeker recieves a press ganey 8 out 10 times they will not even open the mail, half the time they don't even have a address, or its a hotel address. Or they give a fake name like come on with all these nursing managers, nursing supervisor, nursing assistant. I am tired of their bull****. Like is me giving them the 30mg oxycodone they want going to up our press ganey scores.No they would rather see that patient walk out with what they want and go sell it to a 15yr. I would rather have the press ganey in the ****ter then have them selling drugs to the adolesences. Well maybe you should consider to fire all of the nasty nurses that walk around with a attitude. Next time a nurse confronts me i am going to walk away. If you want to be the MD go to medical school.

Most Press-Ganey contracts do not send surveys to patients after their first visit of a quarter or if the diagnosis is chronic pain.

 

[Arcan57]

Most Press-Ganey contracts do not send surveys to patients after their first visit of a quarter or if the diagnosis is chronic pain.

QFT. Also, confronting the nurse in a snide or bitter fashion is usually more trouble than it's worth. It's their job to keep PG scores up and complaints to administration down and thus they have far more time to screw you over than you have to defend yourself. I'm not saying give in, because that road leads to the land of wind and ghosts, but don't dismiss them out of hand either.

"I understand your concerns about Mr. X's treatment. I believe in treating pain as well. However, Mr. X [has diverted drugs]/[sought narcs from multiple providers recently]/[been to the ED numerous times for chronic pain without ever following up with a PCP/clinic for pain management]. He has an allergy to all non-opioid pain medications, so alternative treatment is/was not feasible. So while I appreciate you looking out for the patient, in this case I feel that giving Mr. X narcotics has more harm than benefit."

Then go and document in the medical record, in a non-perjorative way, your reasoning, so if it gets kicked up the chain it's much easier to defend.

 

[gutonc]

Then go and document in the medical record, in a non-perjorative way, your reasoning, so if it gets kicked up the chain it's much easier to defend.

QFT here as well. In this kind of scenario (whether you're disagreeing/arguing with a nurse/consultant/primary physician/family member, whomever) document your assessment and MDM calmly and truthfully. A chart fight will always come back to haunt you (and is really unprofessional to boot).

 

[deleted65604]

What would be some soultions from your experience.

It depends on who has the most power at your hospital and what their current goals and biases are.

If the CEO of your hospital is trying to remake your hospital into a people pleasing, money-making pleasure boat, then they are going to be exerting influence on nursing supervisors, and holding those supervisors responsible for their scores. If your CEO is under the guns from the board, being threatened with termination for lack of improvement in patient satisfaction scores, they will be extra-motivated. Even without external pressure, CEOs tend to have extraordinary goals for the hospital. If they can turn a poor, or mediocre performing/ profiting hospital into very profitable, they are going to become
very marketable and land their next job in some cush, 7 figure job. That is their goal: dramatic results and huge turn-arounds under their supervision.

If the Nursing Supervisor of your department is under the gun from the CEO, they are going to hold the nurses under them to an extremely high standard. If a department has dramatic turn-around, they stand to land a six figure job, with even more cush hours than they already have. They could even land a job as a CEO at a smaller hospital with an MBA, or significant administrative experience.

Some nurses want to become nursing supervisor and thereby not have to do night-shifts, or put up with clinical BS anymore. They are going to get that job by being a patient pleaser, not the embittered nurse who doesn't put up with guff from patients.

This is the reality of modern medicine...everybody is in it for themselves and there is a constant tog of war between patients, doctors, nurses, CEOs, and government interests. This is the healthy competition of capitalism, a constant upward striving for individual interests that balances provider/patient interests. The priority of the individual parties often fail to coincide. When goals and priorities don't coincide, somebody has to lose. On your shift, you lost. Administration is not backing you up and you have some choices:

1. Fight the fight as an individual... which you will lose
2. Get all the physicians in your group to back you and as a group do some political wrangling with administration, which you might lose as a group, leading to loss of your contract
3. Give in.

You choose. Option 1, I don't recommend. Option 2 is a lot of work, and might annoy your colleagues or more importantly, your boss.

 

[xaelia]

...they are going to be exerting influence on nursing supervisors, and holding those supervisors responsible for their scores....

My favorite joyous memory from residency remains working a craptacular overnight on the non-acute side of our ED with a full boatload of patients 8-10 odd patients as the only remaining resident at 5am - and another 10-12 unseen waiting in rooms for up to three hours.

And the nursing supervisor comes into my work area as I'm charting to ask if there's any way I could see patients more quickly, because their performance bonuses are tied to door-to-physician times.

That might have been the shift where I decided if this was my "educational" environment, I wasn't going to bend over backwards for my program anymore.

 

[EctopicFetus]

I just document the crap out of the chart why I didnt give this to the person. I will admit with our online ability to see what rxs have been filled I usually get my justification from there. If I misjudged someone I will give them a few percs. Otherwise I hop in the room, bring my ammo (the print out) and just say, I cant do this and document what I found on our database.

Works great. Then I stick them on pain management and then they get a "golden ticket" so anytime they show up in the ED every other provider sees it.

 

[Arcan57]

Whenever a question about care comes up, always document. In most cases, knowing there is an issue and addressing it in the documentation will make it go away. It's not the thoroughly documented chart on a belly pain gone bad that gets you, it's the patient that wasn't sick when you first saw them and had some psychosocial reason that kept them from following up as they perfed.

Through your training you've gotten (or will get) good at identifying red flags. That doesn't just apply to medical illness. If it seems like their is unexpected tension in the room or in an interaction, there probably is. And while it sucks when you're getting slammed, addressing the cause of that tension is almost always the right thing to do from a patient care/medicolegal/professional standpoint.

 

[old_boy]

It depends on who has the most power at your hospital and what their current goals and biases are.

If the CEO of your hospital is trying to remake your hospital into a people pleasing, money-making pleasure boat, then they are going to be exerting influence on nursing supervisors, and holding those supervisors responsible for their scores. If your CEO is under the guns from the board, being threatened with termination for lack of improvement in patient satisfaction scores, they will be extra-motivated. Even without external pressure, CEOs tend to have extraordinary goals for the hospital. If they can turn a poor, or mediocre performing/ profiting hospital into very profitable, they are going to become
very marketable and land their next job in some cush, 7 figure job. That is their goal: dramatic results and huge turn-arounds under their supervision.

If the Nursing Supervisor of your department is under the gun from the CEO, they are going to hold the nurses under them to an extremely high standard. If a department has dramatic turn-around, they stand to land a six figure job, with even more cush hours than they already have. They could even land a job as a CEO at a smaller hospital with an MBA, or significant administrative experience.

Some nurses want to become nursing supervisor and thereby not have to do night-shifts, or put up with clinical BS anymore. They are going to get that job by being a patient pleaser, not the embittered nurse who doesn't put up with guff from patients.

This is the reality of modern medicine...everybody is in it for themselves and there is a constant tog of war between patients, doctors, nurses, CEOs, and government interests. This is the healthy competition of capitalism, a constant upward striving for individual interests that balances provider/patient interests. The priority of the individual parties often fail to coincide. When goals and priorities don't coincide, somebody has to lose. On your shift, you lost. Administration is not backing you up and you have some choices:

1. Fight the fight as an individual... which you will lose
2. Get all the physicians in your group to back you and as a group do some political wrangling with administration, which you might lose as a group, leading to loss of your contract
3. Give in.

You choose. Option 1, I don't recommend. Option 2 is a lot of work, and might annoy your colleagues or more importantly, your boss.

This is a great post, and accurately portrays hospital dynamics me thinks. Kind of depressing, but I guess the moral is pick your battles. Some battles just aren't worth fighting.

 

[docB]

This is a great post, and accurately portrays hospital dynamics me thinks. Kind of depressing, but I guess the moral is pick your battles. Some battles just aren't worth fighting.

It depends on who has the most power at your hospital and what their current goals and biases are.

If the CEO of your hospital is trying to remake your hospital into a people pleasing, money-making pleasure boat, then they are going to be exerting influence on nursing supervisors, and holding those supervisors responsible for their scores. If your CEO is under the guns from the board, being threatened with termination for lack of improvement in patient satisfaction scores, they will be extra-motivated. Even without external pressure, CEOs tend to have extraordinary goals for the hospital. If they can turn a poor, or mediocre performing/ profiting hospital into very profitable, they are going to become
very marketable and land their next job in some cush, 7 figure job. That is their goal: dramatic results and huge turn-arounds under their supervision.

If the Nursing Supervisor of your department is under the gun from the CEO, they are going to hold the nurses under them to an extremely high standard. If a department has dramatic turn-around, they stand to land a six figure job, with even more cush hours than they already have. They could even land a job as a CEO at a smaller hospital with an MBA, or significant administrative experience.

Some nurses want to become nursing supervisor and thereby not have to do night-shifts, or put up with clinical BS anymore. They are going to get that job by being a patient pleaser, not the embittered nurse who doesn't put up with guff from patients.

This is the reality of modern medicine...everybody is in it for themselves and there is a constant tog of war between patients, doctors, nurses, CEOs, and government interests. This is the healthy competition of capitalism, a constant upward striving for individual interests that balances provider/patient interests. The priority of the individual parties often fail to coincide. When goals and priorities don't coincide, somebody has to lose. On your shift, you lost. Administration is not backing you up and you have some choices:

1. Fight the fight as an individual... which you will lose
2. Get all the physicians in your group to back you and as a group do some political wrangling with administration, which you might lose as a group, leading to loss of your contract
3. Give in.

You choose. Option 1, I don't recommend. Option 2 is a lot of work, and might annoy your colleagues or more importantly, your boss.

I too (unfortunately) have started to fall into this boat.

Call me passive aggressive but when I do try to fight the "no narcs" fight and get nursing against me I often ask them directly "Do you want me to give them narcs?" If they have the balls to take ownership of what they're doing then I document that "I d/w RN and feeling is patient's claim may be legitimate. Therefore to err on the side of treating real pain I am going to..."

I then dictate a note (we rarely dictate, we use T-sheets, but the dictations are much easier to find in the computer system) saying that I am suspicious that the patient is seeking but have treated to give them the benefit of the doubt. I also inform the patient that I have documented their situation and that they are to follow up and will not be getting more narcs from that ED.

 

[sjdcMD]

I really have to pick and choose which battles to fight with nursing admin. DocB i feel the same way. I am going to start asking "do you want me to give them narcs". Honestly its a all sham with the narcs. I give them when i have a medical reason. Unsure if i have access in New Jersey that has all the medications they filled in the last 30 days. I need to look into that. I believe that my back is constantly against the wall on this subject. It's sad. But this is the world we live in.Another MD Actually had a similar case with nursing. Patient came stomped their feet and the doc wouldn't write what they wanted. He wrote for 10 5mg perc's. Well the patient called nursing supervisor and she went to another MD for the patients drug of choice. It's just a revolving circle all the junkies will find out that you just have to make a call to the nursing supervisor and you will most def get your drug of choice. I talked with my associate about this, he said you have a medical license to uphold, it is your decision for what you write for. No NURSING can tell you different. Medical staff is fed up with all the nursing in my hospital. Im not the only one.

 

[RustedFox]

Agree with above. New Jersey is a tough place, too. I did my 3rd/4th years of med.school in Newark. Its a tough joint.

 

[keeping-it-real]

Maybe I'm an outlier, but I'd rather lose my job than give into this. I'm fortunate, though, that the administration at my shop backs us up so long as we have a reasonable justification. We have a very nicely drafted narcotic policy that deals with chronic visitors and non-acute pain.